Dangerous and Severe Personality Disorder Unit DSPD in practice : The Westgate Unit

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The History

• The Government Consultation Paper with Severe Personality Disorder, Proposals for Policy Development (1999) Managing Dangerous People • The 2001 election manifesto published stating that 300 more high-secure prison and hospital places” “to deal with the most dangerous offenders of all – those with a dangerous severe personality disorder – we will pass new legislation and create over • Programme delivery – the DSPD programme was created to “develop, pilot and deliver new services specifically for people who present a high risk of committing serious sexual and/or violent offences as a result of severe personality disorder” 2

Who is involved?

This is a collaborative programme involving: • Department of Health • National Health Service • The Ministry of Justice • Her Majesty’s Prison Service 3

What are its aims?

The target outcomes of the programme are: • Improved public protection • Provision of new treatment services improving mental health outcomes and reducing risk • Better understanding of what works in the treatment and management of those who meet the DSPD criteria 4

Who is the programme for?

An individual will be suitable for admission for treatment to a DSPD pilot unit if assessment indicates: • They are more likely than not to commit an offence that might be expected to lead to serious physical or psychological harm from which the victim would find it difficult or impossible to recover • A severe disorder of personality • Their offending is linked to personality disorder 5

What are the programme objectives?

To enhance public protection and improve mental health outcomes by better understanding: • How to identify, assess and treat those who are dangerous and severely personality disordered • The nature and challenges of treatments and service delivery involving multi-disciplined teams working across agencies • The extent to which treatment might reduce (or manage better) the risks of re-offending and how best to move on those offenders who have benefited from the programme, as well as those who have not • To strengthen the clinical, service delivery and policy evidence base in this area, informing the options for future services, and the costs and benefits 6

What have we achieved?

• Designed and built or newly modified 9 units • Established guidance and commissioning arrangements • Led strategic planning for severe personality disorder • Commissioned services and training initiatives • Identified financial resources • Developed monitoring and improvement arrangements • Designed a research programme and systems for disseminating learning • Established multi-disciplinary methods of working • Undertaken a Stocktake Review 7

What have we leant to date?

• Too soon to come to a view about effectiveness • Service delivery is complex and difficult • Developing a competent and confident workforce is key – more so than the buildings • The patient group is too heterogeneous and difficult to manage solely in one setting • The conditions and risks are almost certainly life-long – we might hope to reduce risks so that some can be managed in less intrusive ways • Risk reduction needs to be tested in different environments – hence the need for managed pathways • Those released into the community will continue to need supervision and aftercare 8

Westgate Unit

• Purpose built unit – opened in May 2004 (£14m build cost) • Based within the walls of Frankland High Security Prison • 80 beds (soon to be 86) • Assessment and Treatment processes supported by a complementary regime including education, gym and horticulture • Primary Care facilities on site – skills mix within nursing team • WAMMS - Timetabled ‘options’ regime, 4 sessions per day 9

Staffing

• Staff members (N = 175) 126 Operational staff 21 Psychologists 9 Administrative staff 7 Westgate Therapists 3 Researchers 3 Progression 3 Horticulturalists 2 Cleaners 1 Substance Misuse Worker • Also have education staff and provide some finance for staff contained within main establishment’s budget (eg DST, RESPECT, Chaplain and OSGs) 10

DSPD Referral Process

• Standardised referral form that requests information from variety of sources • MDT referral panel at each site • DSPD Roadshows • To date Westgate Unit have processed over 500 referrals • Referring staff and prisoner informed in writing • Joint referral panels with Rampton Hospital 11

Westgate Unit Ethos

Conditions of Success

Participate constructively at all times Keep an open channel of communication Be respectful at all times

Strategy of Choices

Working with prisoners to explore all options and their consequences in a given situation to encourage them to take responsibility for their own choices/decisions 12

Assessment Process

• • • • The assessment process at Westgate Unit consists of two stages : 1) DSPD Criteria Assessment 2) Westgate Individual Treatment Needs Analysis and Progression (WITNAP) MDT approach to all elements of assessment Triangulated approach also adopted NB : DSPD is not a clinical diagnosis, though the disorders used to determine a prisoner’s suitability for DSPD services are clinically-based 13

DSPD Criteria Assessment

• DSPD services are considered suitable if the following criteria are met:

Dangerousness:

The individual is more likely than not to commit an offence that might be expected to lead to serious physical or psychological harm from which the victim would find it difficult or impossible to recover

* Severe Personality Disorder:

* * A PCL-R score at the 95.8 percentile or above (or the PCL-SV equivalent) compared to a British norm group; or PCL-R score falling between the 85.2 and 94.4 percentile (or the PCL SV equivalent) plus at least one DSM-IV personality disorder diagnosis other than anti-social personality disorder; or Two or more DSM-IV personality disorder diagnoses

The offending is linked to personality disorder.

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Common Data Set

• Risk Tools: – HCR-20 – VRS – RM2000 – Static 99 • Personality Tools: – PCL-R – IPDE • Mental Health Tool: – SCID 1 15

Criteria Assessment Process

• MDT Approach Including : chartered forensic psychologist, trainee psychologists, psychological assistants, psychiatrist, discipline officers, general/psychiatric nurses. Can also include: gym, education,horticulture, chaplaincy staff • 4 week assessment period • Collateral searching / Prisoner interviews / Scoring of assessment tools and Report writing • MDT case conference • Feedback to prisoner • Exclusion criteria – mental health? IQ? Denial? Motivation?

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WITNAP

• Westgate Individual Treatment Needs Analysis and Progression • Successful offender treatment interventions found to consider principles of RISK and TREATMENT NEED, alongside

RESPONSIVITY

• Pre-treatment WITNAP process establishes a comprehensive treatment plan based on all 3 principles • WITNAP process also involves assessing progress following completion of Westgate treatment interventions 17

WITNAP Aims

• Explore relevance of treatment need areas to offending behaviour  and personality disorder • Identify individualised treatment need areas • Highlight appropriate treatment modules Assist preparations for future group work through an experiential learning sub-module called WITNAP – Parallel Therapy • Employ a collaborative approach • Develop insight • Develop responsivity plan • Enable progress made by prisoners following treatment to be evaluated in light of pre-treatment level of functioning 18

WITNAP Treatment Domains

• Treatment need areas identified in WITNAP are directly linked to Westgate Clinical Framework domains: – Self Management – Social and Interpersonal Competencies – Thinking Processes, Attitudes and Beliefs – Offending and Offence Interests – Progression 19

WITNAP Process

• 10 week process • Group and individual work • MDT • Interviews, psychological testing, offence analysis, parallel therapy, collaborative feedback to gain a better understanding of level of insight, knowledge, coping strategies and ability to generalise skills • Motivation and Engagement component of Chromis © • MDT case conference 20

Assessment and WITNAP diagram

DBRS Review Wing History Review WITNAP PT Session Obs DSPD Criteria Assessment

Wk1 – Intro & IPDE Interview Wk2 – Combined Interview & Scoring Wk3 – Report Writing

Criteria Assessments Scored by Assessment Team:

HCR-20, VRS, PCL-R, IPDE, RM2000, Static-99, SCID1

Case Review: Suitable? No

Complete Criteria Report Wk4 – Report Writing Wk5 – Full Disclosure

Referral to Appropriate Service Yes WITNAP

Wk 4 – Intro, Consent, “How I see my needs” Wk 5 – Psychological Testing Wk 6 – Offence Analysis Wk 7 – Personality Disorder Feedback Wk 8 – Collaborative Interviews on need (including psychometric feedback) Wk 9 – Collaborative Interviews on need (including psychometric feedback) Wk 10 – Progression, Debriefing, “HISMN” Wk 11 – Report Writing

Case Review: Suitable? No

Psychological Tests Analysed by Research Dept: PRD, ADS, DAST, SPSI, BIS, SSS, NAS-PI, LOC, PTQ, RQ, PICTS, YSQ, SIV, IIP, STAXI, BECKS, SOTP BATTERY, MSI, SARN Complete WITNAP Wk12 – Report Writing Wk13 – Full Disclosure

Referral to Appropriate Service Yes

Wk 12 – Report Writing Wk 13 – Full Disclosure Complete WITNAP

Treatment at Westgate

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Establishing the Functional Link

• Trait-based approach that explores “links” rather than single link • Trait level propensities can be explicitly linked with risky behaviours • Individuals have a range of traits that make up their personality disorders • Therefore, likely to a range of functional links between traits that make up their personality disorders and their risk • Understanding and managing influence of PD traits on individual’s responsivity is of equal importance to clinical considerations about functional links between PD and risk • Some PD traits may not be linked to risk but may function as obstacles to their engagement with treatment designed to address risk • Functional links developed collaboratively with individual 22

DSPD Prisoners

Common misconceptions • Media and cinematic stereotyping: Hannibal Lecter, Norman Bates, Patrick Bateman, etc.

• Prisoners with personality disorders are ‘mad’, ‘unstable’, ‘violent’ and ‘untreatable’ The reality: • Age?

• Offence type?

• Sentence length?

• Mad?

• Personality Disordered?

• Psychopathic?

• Violent?

• Treatable?

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Westgate Unit’s Clinical Framework

• Risk reduction is primary focus of treatment at Westgate • Integrated approach to treatment – drawing on CBT, DBT and psychodynamic approaches (“One size does not fit all”) • CHROMIS – currently the only site delivering CHROMIS © • Aim - To teach prisoners the skills to make choices in their lives that still allow them to reach the goals that are important to them, but without causing harm or problems for others (i.e. injury, distress) or for themselves (i.e. custody) • Aim - To help prisoners to self-manage the problems associated with their personality disorders, rather than to try to ‘cure’ them 24

The Clinical Framework continued

• Domain based approach * Psycho Education * Self Management * Social and Interpersonal * Thinking Processes, Attitudes and Beliefs * Offending and Offence Interests * Progression • It is estimated that it will take prisoners up to 5 years to complete their individualised treatment within the Westgate Unit model. • Individual sessions (2:1 working policy) • Group sessions (max 5 prisoners) 25

Psycho Education Domain

• This domain of treatment aims to develop the offender’s understanding of the fundamental concepts within DSPD and how they relate to him as an individual. • A number of modules are offered within this domain: Boundary Setting Risk Assessment Awareness Personality Disorder Awareness Introduction to Treatment • Trauma Psycho Ed for those who require it • Also delivered to staff as part of the induction programme and ongoing CPD 26

Self Management Domain

• This domain focuses upon self-management skills: specifically in relation to a prisoner’s ability to plan, problem-solve, regulate impulses and regulate emotions so as to better achieve long term goals. • A number of modules are offered within this domain Iceberg (substance misuse) Emotion Modulation Creative Thinking © Handling Conflict © Problem Solving © 27

Social and Interpersonal Competencies Domain

• This domain is concerned with how an individual relates to others, how he thinks and feels about himself and others and the impact of these on his social skills • Two modules are offered within this domain: Social and Interpersonal Competencies Relationship and Intimacy skills 28

Thinking Processes, Attitudes and Beliefs Domain

• This domain focuses on the attitudes and beliefs driving the internal (thoughts and feelings) and external (actions) behaviour of the individual • Work concentrating on developing the understanding of cognitive distortions, automatic thoughts, core beliefs and schemas held by individual prisoners, is completed throughout the Westgate Clinical Framework • In addition, Westgate Unit has a number of trained cognitive therapists who are able to provide specialised treatments within this area (including social phobia, depression, OCD) 29

Offending and Offence Interests Domain

• Currently in development • Will include modules to address * Violent Offending – CSCP © * * Arson Sexual Offending – PPG, HSF * Domestic Violence • Important to note that all our treatment addresses risk factors associated with offending - It is expected that these modules will build on the work and skills developed during the previous domains in order to develop understanding of the relevance of treatment need areas within the specific context of offending behaviours 30

Parallel Therapy

• Activity-based intervention to complement formal, classroom-based treatment • Delivered in different complementary regime settings (e.g., gym, horticulture, education) • Delivered by Parallel Therapists, Formal Therapists and Complementary Regime Professionals • Delivered to a staff-prisoner group, which is directed by prisoner participants • Makes the prisoner progress during treatment observable: subject to behavioural monitoring • Provides activities that promote therapeutic alliance • Designed to reinforce treatment objectives of specific Formal Therapy (FT) sessions through experiential learning activities • An opportunity to take ‘processes’ from a classroom environment and practice them in environments that are closer to ‘real life’ 31

Clinical Practices continued

• DBT • Trauma • Self Managing Self Harm • GLAD – Westgate’s alternative to the IEP scheme • LINKS • Substance Misuse Team • Stress Busters 32

Generalisation

• Behavioural Monitoring • Coaching / Mentors • Parallel Therapy • Review mechanisms include CPA, sentence planning and WITNAP reviews • Measurement of awareness of need, knowledge of skill and ability to apply skill 33

Progression Reviews

• Post module reviews including objective setting • Yearly WITNAP reviews which aim to : – Update progress in each need area found to be relevant in pre treatment WITNAP process – Identify new targets to address areas of treatment and responsivity need and risk reduction • Includes re-administration of HCR-20 and VRS (changes calculated on basis of changes in WITNAP factors) • All reviews are multi disciplinary with significant others also being invited 34

Progression

• Proactive and very skilled progression team at Westgate Unit • Keen to ensure the establishment of suitable step down/ step across / progression sites both within and outside of the Prison Service • Prisoners can be given lateral transfers to special hospitals under section where applicable (i.e. if their determinate sentence ends and they’re still deemed high risk) • Prisoners may alternatively progress to lower security prisons, hospitals, or release under ‘MAPPA’ • Development of a progression domain – employment, social networks, long term goal planning etc • Relapse prevention work will be ongoing following the prisoner’s departure from Westgate as will continued monitoring 35

Development Centre

• Co-developed with the Chromis Team • Offered to all staff seeking to be involved within clinical practice at Westgate Unit • Four competencies assessed via four different exercises : * Problem Solving * Team Playing and Networking * Communicating Clearly * Analytical skills • Skills development plan and recommended roles • To date over 150 staff have completed the Development Centre 36

Clinical Integrity and Staff Support

• Audit • Clinical Governance • 2:1 working policy / Maximum of five prisoners per treatment group • Carefirst / Health reviews • 4x daily briefings • Continued staff development, support and supervision 37

Research at Westgate Unit

• The Unit is headed by Dr Mark Freestone, who is also an Honorary Senior Research Fellow at the University of Durham and a co-chair of the Personality Disorder Institute.

• The Research Centre maintains strong links to established research environments at the Universities of Durham and Newcastle as well as the new Personality Disorder Institute established in Nottinghamshire Healthcare NHS Trust. • Some of the current research projects ongoing or recently established within the Centre include: – Clinical effectiveness of new treatments for psychopathy (Mark Freestone/OBPU) – – – – – – Validation Study of the Violence Risk Scale (collaboration with Oxford University and Broadmoor Hospital) Development of a ‘parallel therapy’ in a complementary regime (Jason Morris) DSPD Ward climate and therapeutic effectiveness (Karen Twiselton in collaboration with Rampton Hospital) The Collection of a DSPD Minimum Data Set (Imperial College/Westgate Unit) Inclusion for DSPD: Evaluation and Assessment (Oxford University) Ethnographic Investigation of the DSPD Pilot Sites (Mark Freestone) 38

The Future

• Does it work?

• Joint working • Review of referral procedures (DSPD spaces are a limited resource) • Research • Roll out further treatment modules • Progression • Accreditation 39

Contact Details

• John Buckle – DSPD Programmes Unit [email protected]

• Kim Gibson – Assessment Lead, Westgate Unit [email protected]

• Emma Clark – Treatment Lead, Westgate Unit [email protected]

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